23.1 Introduction

The neurosurgical intensive care unit (NICU) faces unique challenges when it comes to providing patient safety. Neurologic patients are often confused, impulsive, restless, and agitated. They may lack the ability to make sound judgments regarding their medical care. Frequently neurologic patients are unaware of their physical limitations. We as health care providers are confronted with the responsibility to protect our patients from physical harm, while preventing psychological distress.

Restraint reduction is the primary intent of the Joint Commission on Accreditation of Healthcare Organizations’ (JCAHO) 2004 Patient Care Initiatives. ¹ Centers for Medicare and Medicaid Services (CMS), formerly Health Care Financing Administration (HCFA), guidelines also focus on restraint reduction. Both institutions regard restraints and seclusion as last resort measures and encourage acute care hospitals to use them only when less restrictive means fail.

Restraint use must be guided by state and federal law as well as hospital licensing or facility accreditation requirements.

Restraint can be defined as any device or method used to restrict a person’s movement, mobility, or access to one’s body. ² Medical restraint can be applied in a variety of settings for a variety of reasons. When restraint is used to promote medical treatment, such as intravenous (IV) therapy and medications; to prevent pulling lines and therapeutic tubes, such as endotracheal tubes, indwelling catheters, intracranial monitors or drains; or to prevent disturbing surgical dressings and incisions, it is considered medical restraint, no matter the hospital setting. All other alternative means of preventing the undesired behavior should be exhausted before application of restraint. By allowing patients to harm themselves by self-extubation or pulling out a subdural drain, or other medically necessary device, demonstrates a failure of patient safety.

Patient safety must be foremost when using restraints. JCAHO Sentinel Event Alert 1998 reports 20 deaths in the previous 2 years of patients in restraints. ³ These deaths had various root causes. Death by strangulation occurred in geriatric patients with vest restraints, half of whom made their way between split side rails. Forty percent of deaths occurred as a result of asphyxiation, and the remainder were due to cardiac arrest and fire (while the patient was attempting to burn off restraints). JACHO identified the following as potential contributing factors:

• 
  

  Restraint of smokers.

  
  
• 
  

  Restraint use with physical deformities that prevent proper application (especially vests).

  
  
• 
  

  Supine position may predispose patients to aspiration.

  
  
• 
  

  Prone position may predispose to suffocation.

  
  
• 
  

  Not continually observing patients in restraints.

Care should be taken to decrease the risk of problems such as those listed above. All smoking supplies should be removed from the patient’s belongings and environment. Visitors should be advised of smoking restrictions due to fire risk. A thorough needs assessment for a planned restraint device, considering the patient’s unique physical requirements, must be carried out prior to the application. While a patient is restrained, proper positioning and observation are imperative. A nonintubated patient with an altered level of consciousness should not be restrained flat on his back due to the risk of aspiration. The head of the bed should be elevated whenever possible. Rarely will a neurologic patient need to be restrained in the prone position. If the prone position is used, the airway must be kept unobstructed at all times. The prone position is not recommended for obese, elderly, or pediatric patients.

Mindfulness of the patient’s long-term immobility due to restraints is essential. Despite the described benefits of safety with restraints, the risks of immobility due to the restraints must be considered. Evidence shows that mobility is associated with improved outcomes in the ICU. ⁴ Frequent turning and multiple mobility sessions daily are especially essential in the restrained patient.

JCAHO’s Provision of Care, Treatment and Services (PC), PC.11.10 through PC.11.100, delineate appropriate measures for restraint use in hospitals. ¹ These standards establish that assessment and reassessments of the need for restraint, and alternatives to use are carried out according to hospital policy. Additionally, hospital leaders must set forth the hospital’s philosophy regarding any standards for restraint use and define the situations where restraint use is allowable based on clinical evidence. Hospital policies will direct appropriate patient use of restraints. Restraints must either be ordered by a licensed independent practitioner or applied upon specific order according to a hospital-approved protocol that defines clinical criteria for use. Patients are to be monitored while in restraints, and restraint use is to be thoroughly documented in the patient’s medical record according to hospital policy. The hospital works via its performance improvement process to find ways to prevent use, develop alternative measures, and improve processes to decrease the risk related to restraint use. These standards are not intended to address behavioral restraint. Restraint should never be used as a disciplinary measure.

23.2 Types of Medical Restraints

There are many different types of restraints used for medical necessity to ensure the safety of the confused, combative, and psychotic patient ⁵ ; all of which behaviors can be found in the neurologic or neurosurgical patient. Patients with traumatic brain injury can present agitated, combative, and confused to the point where restraints must be used to ensure the safety of the patient as well as the safety of hospital staff. The choice of restraint must be considered in terms of its appropriateness for the patient. Restraints alone can cause agitation in an already confused patient and can cause deadly harm. Restraints should only be used as a last resort with the least restrictive device as possible. ⁶ Removal of all restraint devices should be achieved as soon as safely possible.

Related posts:

9 Homeostatic Mechanisms in the Neurosurgical Intensive Care Unit Patient 8 Sedation and Pain Management in the Neurosurgical Intensive Care Unit Patient 7 Delayed Intracerebral Hemorrhage 22 Anticoagulation and Antiplatelet Therapy in the Neurosurgical Intensive Care Unit 28 Family Communication 21 Cerebral Microdialysis in the Neurosurgical Intensive Care Unit

Stay updated, free articles. Join our Telegram channel

Join